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Sunday, 11 November 2012

Lessons from history #4: RSI

Repetitive Strain (or ‘Stress’) Injury (RSI) is a syndrome of
arm / hand pain associated with certain activities. It is not a disease. It is
not an injury, there is no physical evidence of stress or strain, and it bears
little correlation with repetitive use. It is a social construct, influenced
more by psychosocial factors than mechanical factors, and has no clear
biological basis. Its history shows us how ‘unstable’ such labels are. Yet
despite being easy to refute, labels like these persist. They persist because
they serve a purpose and appear to fill a gap in our knowledge, and they are
more socially acceptable and easy to understand than the truth. They are
examples of medicalization.

The incidence of RSI rose rapidly
in the mid 1980’s in Australia, particularly in Canberra and Sydney where it
reached epidemic proportions (here
and here). The
condition was diagnosed through subjective complaints from workers, as there
were no tests available and there was no discernable underlying pathology,
despite theories regarding inflammation and nerve injury. At the time, RSI was
attributed to the introduction of the computer keyboard, which replaced the
typewriter in the 1980s. As computers allowed faster keystrokes than a
typewriter, it was felt that the increased typing speed caused an injury to the
structures in the hand and wrist. It was a good example of something that ‘made
sense’ if you didn’t think about it too hard or for too long, and it was
therefore assumed to be true.

It is interesting to note the similarity between RSI and
writer’s cramp and telegraphers’ cramp (from a century earlier) in that they were
all associated with the introduction of new technology (steel tip nib and
telegraph), and all appeared to be transmitted by line-of-sight. That is, the
incidence of both diseases was largely confined to groups of workers, usually
in one building or company. The clumping of these diseases has led to causative
theories relating not to any biomechanical factors, but to hysteria,
employee-employer relations (here,
item 15), and malingering.

Occurring
mainly in the workplace, RSI fell under workers compensation. Like many other
conditions associated with compensation, physical theories have been put
forward, but none were proven or widely accepted. And like these other
conditions again, RSI was thought to be associated with many psychosocial
factors. Tertiary gain by health professionals, including doctors,
physiotherapists and occupational therapists, all of whom stood to gain from
having RSI established as a medical, and work-related condition, was thought to
be a contributing factor. Concern from the union movement (which resulted in workplace
lectures and publications such as “The sufferer’s handbook”) and misinformation
and exposure in the media were also thought to contribute (here,
item 15). As an example, one media headline at the time read: “Hi-tech
epidemic. Victims of a bright new technology that maims” (National Times, Oct
12 1984), and another read: “A crippling new epidemic in industry” (New Doctor
1979, 13:19-21).

Although RSI reached epidemic proportions in the 1980s, in Australia
compensation for the condition was eventually denied due to a lack of physical
evidence of a disease process, epidemiological evidence of the condition
occurring in distinct clusters, and being unrelated to workplace conditions
such as the typing speed or the number of keystrokes used (here,
here and here). There was a rapid
decline in the incidence of the condition after claims for compensation were
rejected.

A review
of the literature regarding risk factors for upper limb pain concluded that
perceived high job stress and non-work related stress were consistently
associated with all upper extremity problems, and that the association with physical
job demands was often not significant.

The search for biological abnormalities and medical
treatments for symptoms that are expressions of ‘dis-ease’ (unease, anxiety, workplace
conflict and other psychosocial phenomena) rather than disease is an example of
our tendency to medicalize any ‘complaint’.

9 comments:

In that last review it stated "Although not often studied, non-work-related stress was also consistently associated with Upper Extremity Pain." This is consistent with an anxiety disorder pre-dating onset of chronic pain, as shown in Gupta A et al. Rheumatology 2007. This showed that anxiety disorder is present in 95% of new chronic pain patients before they get the pain.

If you add to anxiety and chronic pain the known effects of disuse atrophy then you get the clinical picture of RSI. We still have doctors treating it like a medical-only complaint however.

Thanks. The role of a person's pre-morbid psychological profile is interesting. DIfficult to measure, but very important. Most would agree that certain "types" of people are more likely to develop these conditions.

Good post. There are quite a few conditions that are not correlated with anatomical or biochemical abnormalities: low back pain (nothing is found with imaging in up to 70% of patients), chronic fatigue syndrome, chronic pain conditions etc. Finding something to throw a pill at doesn't always work.

Thanks, and there is also a risk involved with labelling (diagnosing) things that we not certain about. Apart from the effect on the patient, we then provide a compartment into which other patients may be fitted.

I'm 74, have osteoarthritis - knees, neck, hands - with hobbies of crocheting, hand sewing, and polishing old aluminum kitchen collectibles with steel wool (that sometimes for hours.) Pain in my hand and wrist have made me stop these activities for short periods until I just have to get back at it. I've had arthroscopy on one knee about 8 years ago when I was told I was buying time for replacement. It was suggested by three doctors that I try glucosamine-chondroitin. I did - I've been taking Osteo-Biflex ever since then, with almost miraculous results, especially in my neck. Mind over matter? I don't know, the difference is amazing. My knees seem better, although I know my limits and adjust accordingly. But recently I've developed pain up my arm into my shoulder where it's worse after stitching for five minutes or so. I was thinking it's repetitive motion injury, and have decided that only rest will help. The pain subsides or goes away when I'm not moving my arm. Or are my days of using/abusing my hand/arm movement over? Would you call this repetitive motion injury?

If you have pain that limits your ability to perform your daily activities and it is bothering you, it is reasonable to seek advice from your doctor regarding the possible cause and possible treatment. You could have a treatable condition.

However, many conditions, like arthritis for example, cause pain with movement. It is the underlying condition that causes the pain, rather than the movement per se. Therefore, it is not reasonable to attribute pain with movement to a "repetitive movement injury". It just hurts to move, we don't need any new diagnoses or labels to add to our already impressive collection.

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This blog explores the true effectiveness of medical interventions, established through scientific study, as opposed to the perceived effectiveness. This highlights our overestimation of the benefits and underestimation of the harms from these interventions.

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Why be skeptical about medicine?

Doctors and skeptics are often critical of alternative medicine and other non-medical healing practices because they are not well supported by scientific evidence. This is appropriate.What is inappropriate is the acceptance of medical practices (established and new) without a requirement for the same level of scientific support.The evidence supporting many medical practices is less than many people suppose, and similarly, the harms from medicine are often under-appreciated.We need to ask the same question of medicine that we would ask the alternative practitioner: what is the evidence? But we need skills to be able to critically appraise that evidence, because unlike (say) homeopathy, medical evidence is based on science. This is part of the problem because for many, being scientifically based is reason enough for a treatment to be accepted as true; assuming that a medical treatment works is our default position. This, and the other biases that creep into medical science on so many levels, at least partly due to our keenness to see it work, are the reasons for looking at medicine with a skeptical eye.